Rigolin MDS 2019 — Laurea Magistrale in Medicina e chirurgia

Sindromi

_{mielodisplastiche}

prof. Gian Matteo Rigolin

WHO classification of myeloid neoplasms and

acute leukemia

1. Myeloproliferative neoplasms (MPN)

2. Myeloid/lymphoid neoplasms with eosinophilia and rearrangement of PDGFRA,

PDGFRB, or FGFR1, or with PCM1-JAK2

3. Myelodysplastic/myeloproliferative neoplasms (MDS/MPN)

4. Myelodysplastic syndromes (MDS)

5. Acute myeloid leukemia (AML) and related neoplasms

6. Blastic plasmacytoid dendritic cell neoplasm

7. Acute leukemias of ambiguous lineage

8. B-lymphoblastic leukemia/lymphoma

9. T-lymphoblastic leukemia/lymphoma

MDS: definizione

Gruppo eterogeneo di disordini clonali della cellula staminale,

contrassegnati da citopenia periferica e nella maggior parte dei

casi da un midollo ipercellulato con evidenti alterazioni

maturative (displasia).

Le MDS presentano un aumentato rischio di evoluzione in LAM.

MDS incidenza

Zeidan et al. Blood Reviews 2018

Incidence of MDS or AML in the

USA (Surveillance, Epidemiology,

and End Results data, based on

the Nov 2017).

MDS: incidenza

Zeidan et al. Blood Reviews 2018

Incidence of MDS or AML in the

USA (Surveillance, Epidemiology,

and End Results data, based on

the November 2017 submission).

Sopravvivenza a 5 anni

Five-year overall survival of cancer patients in the United States (Surveillance, Epidemiology, and End Results data, based on the November 2017 submission).

Eziologia

• La causa delle MDS è di solito sconosciuta.

• In alcuni casi una MDS può svilupparsi dopo

l’esposizione a radiazioni, ad alcuni tossici

ambientali quali il benzene o dopo trattamenti

con alchilanti o inibitori delle topoisomerasi II per

una precedente neoplasia

MDS

• The cause is known in only 15% of cases

• Inherited predisposition

– is evident in a third of paediatric cases, including in children with Down’s syndrome, Fanconi’s anaemia, and neurofibromatosis. – In adults, inherited predisposition is less common but should be

investigated in young adults or in families with other cases of MDS, AML, or AA.

• Environmental factors include previous use of

chemotherapy,especially of alkylating agents and

purine analogues,radiotherapy,and tobacco smoking.

• Recognised occupational factors include exposure to

benzene and its derivatives,

and an excess of cases is

reported in agricultural and industrial workers.

Pathogenesis of

MDS

Citogenetica

• Anomalie citogenetiche sono

riscontrabili del 40-70% delle

MDS de novo e nel 95% delle

forme secondarie a

chemioterapia (therapy-related)

•

Ogawa S. Blood. 2019 Mar 7;133(10):1049-1059.

Common driver

alterations in MDS and

other myeloid

Ogawa S. Blood. 2019 Mar 7;133(10):1049-1059.

Common driver

alterations in MDS and

other myeloid

Ogawa S. Blood. 2019 Mar 7;133(10):1049-1059.

Major driver genes

in MDS

Nucleosomes consist of DNA (black line) wrapped around histone octomers (purple).

Post-translational modification of histone tails by methylation (Me), phosphorylation (P) or acetylation (Ac) can alter the higher-order nucleosome structure.

Nucleosome structure can be regulated by ATP-dependent chromatin remodellers (yellow cylinders), and the opposing actions of histone acetyltransferases (HATs) and histone deacetylases (HDACs). Methyl-binding proteins, such as the methyl-CpG-binding protein (MECP2), target methylated DNA (yellow) and recruit HDACs.

a. DNA methylation and histone deacetylation induce a closed-chromatin configuration and transcriptional repression. b. DNA demethylation and histone acetylation relaxes chromatin, and allows transcriptional activation.

Clonal hematopoiesis (CH)

• WGS of 11.262 Icelanders reveals that CH

is very common in the elderly.

• Somatic mutation of some genes is

strongly associated with CH, but in most

cases, no driver mutations were evident

(12.6%, 177/1403).

• CH is associated with increased mortality

rates, risk for hematological malignancy,

smoking behavior, telomere length,

Y-chromosome loss, and other phenotypic

characteristics.

Clonal Hematopoiesis and Blood-Cancer Risk

Inferred from Blood DNA Sequence

• whole-exome sequencing of DNA in PB cells from 12,380

persons, unselected for cancer or hematologic

phenotypes from Swedish national patient registers.

• Clonal hematopoiesis with somatic mutations was

observed in 10% of persons older than 65 years of age

but in only 1% of those younger than 50 years of age.

• Clonal hematopoiesis was a strong risk factor for

subsequent hematologic cancer (HR, 12.9; 95%

confidence interval, 5.8 to 28.7).

G eno ve se e t al , N Eng l J Med 20 14 ;3 71 :2 47 7 -87 .

Clonal hematopoiesis of undetermined potetial (CHIP)

Steensma et al, Blood 2015;126:9

ICUS: idiopatic cytopenia of undetermined significance CCUS: clonal cytopenia of undetermined signficance

Clonal evolution of CHIP

• Investigators have focused on

various MDS- and

AML-associated phenomena that may

aid and abet clonal evolution.

• The primary driver of

progression of CHIP to overt

neoplasia has been assumed to

be acquisition of new mutation in

a clonal cell with self-renewal

properties.

David P. Steensma, ASH 2018

CHIP as a precursor state for hematological neoplasms.

Molecular abnormalities in del(5q) MDS

Decreasing RPS14 expression enhances other ribosomal proteins (RPs) such as RPL11 or RPS19, which sequester MDM2, an E3 ubiquitin ligase that also negatively regulates TP53.

Elevated TP53 activation leads to enhanced TP53-dependent apoptosis of erythroid progenitors.

Molecular pathogenesis

of 5q-syndrome

CK1α: casein kinase 1α,

Molecular pathogenesis

of 5q-syndrome

LEN decreases expression of CK1α.

Normal cells treated with LEN can survive because 50% of CK1α expression remains.

In del(5q) cells, CK1α is at 50% due to haploinsufficiency, so LEN treatment is lethal to

cells by completely losing CK1α.

If del(5q) MDS cells acquire TP53 loss-of-function mutations, they would become

resistant to LEN because complete loss of CK1α could not induce TP53-dependent

Mohamedali and Mufti, BJH 2008;144:157

Ribosomal biogenesis and BM falilure syndromes

Valutazione morfologica sangue periferico e midollare

• Valutazione morfologica sangue periferico per orientamento

diagnostico

– diagnosi differenziale, segni di displasia, presenza di blasti

• Valutazione morfologica midollare:

– Riscontro di segni di displasia

– La valutazione morfologica dei blasti

• La % di blasti valutata su almeno 500 cellule (almeno 100 cellule non eritroidi)

• Non raccomandata la valutazione citofluorimetrica

Caratteristiche morfologiche di displasia

filiera Nucleare Citoplasmatica eritroide Multinuclearità, carioressi,

mitosi anomale, megalobastosi

Vacuoli, difetti di emoglobinizzazione, sideroblasti ad anello

granulocitaria Forme Pseudo-Pelger,

ipersegmentazione, nuclei ad anello, forme giganti, clumping cromatinico, granulociti binucleati

Ipogranulaione, corpi di Dohle, vacuolizzazioni, difetti di mieloperossidasi

megacariocitaria Micromegacariociti, forme mononucleate,

megacariociti con nuclei dispersi

Asincronia nucleo/citoplasmatica, piastrine giganti, piastrine ipogranulate o granulate

monocitaria Ipersegmentazione, nuclei con forme bizzarre

Aumentata basofilia citoplasmatica, granulazioni prominenti

Displasia eritroide

Displasia eritroide

Displasia eritroide

disgranulopoiesi

Blasti e pseudo Pelger

Corpi di Dohle

Displasia megacariocitaria

Sideroblasti

Haematologica 2008; 93:1712-1717.

Il Working Group ha definito 3 tipi di sideroblasti:

– Tipo 1: meno di 5 granuli di ferro nel citoplasma;

– Tipo 2: 5 o più granuli di ferro, ma non in una distribuzione perinucleare;

– Tipo 3 o sideroblasti ad anello: 5 o più granuli in posizione perinucleare, che circondano il nucleo o interessano almeno un terzo della

circonferenza nucleare.

Nel conteggio dei sideroblasti ad anello, occorre valutare almeno 100 precursori eritroidi nei vari stadi maturativi. La percentuale di sideroblasti ad anello ai fini della

classificazione rimane il 15% come per la classificazione FAB e WHO.

blasti e promielociti nelle MDS

Aspetti

cellulari non granulato Blasto granulato Blasto Promielocito normale Promielocito displastico Nucleo Centrale di forma variabile Centrale di forma variabile Ovale, rotondo, indentato Centrale od eccentrico Ovale, rotondo, indentato in posizione eccentrica

Cromatina fine fine Fine od intermedia Fine o grossolana

Nucleolo 1-2 1.2 Ben riconoscibile Ben visibile

Zona Golgi Non evidente Non evidente Ben visibile Presente ma poco sviluppata Granuli Non visibili Presenti (talora

corpi di Auer)

Azzurrofili

uniformemente dispersi

irregolare presenza e distribuzione Citoplasmaa basofilo basofilo basofilo Basofilia ridotta ed

irregolare

Criteri diagnostici minimi nelle MDS

A. Prerequisiti

1. Citopenia costante in una o più delle seguenti filiere: Hb <11 g/dL, ANC < 1500 uL o PLT <100,000 uL 2. Esclusione di tutti gli altri disordini come causa della citopenia/displasia

B. Criteri decisivi correlati alla MDS

1. Displasia in almeno il 10% di tutte le cellule o >15% di sideroblasti ad anello 2. 5–19% di cellule blastiche nello striscio midollare

3. Anomalie cromosomiche tipiche (citogenetica o FISH)

C. Co-criteri (per i pazienti che soddisfano i criteri A ma non quelli B) 1. Anomalo fenotipo mediante citometria a flusso

2. Anomalie molecolari (gene chip profiling, o mutazioni puntiformi (RAS, etc) 3. Anomalie colturali dei progenitori midollari e/o circolanti (CFU-assay)

• La diagnosi di MDS può essere formulata quando entrambi i prerequisiti ed almeno un criterio

decisivo sono soddisfatti.

• Se nessun criterio decisivo è soddisfatto, ma è molto probabile che il paziente sia affetto da una neopasia mieloide clonale, i co-criteri devono essere applicati e possono aiutare nel raggiungimento della diagnosi di MDS o di una condizione definita ‘fortemente sospetta di MDS’.

Citopenia idiopatica di incerto (indeterminato) significato (ICUS)

Definizione

Citopenia in una o più delle seguenti filiere (per più di 6 mesi):

Hb < 11 g/dL; neutrofili <1500 uL; piastrine <100,000 uL

Esclusa una MDS

Escluse tutte le altre possibili cause di citopenia Indagini iniziali richieste per la diagnosi di ICUS

Anamnesi dettagliata (farmaci, tossici, mutageni, etc.)

Attento esame clinico comprendente indagini radiologiche ed ecografia splenica

Emocromo con conteggio differenziale al microscopio e completa valutazione biochimica clinica Biopsia osteomidollare ed immunistochimica

Aspirato midollare e colorazione per il ferro. Citometria a flusso midollare e sangue periferico

Analisi cromosomica con FISH (pannello standard minimo: 5q31, CEP7, 7q31, CEP8, 20q,CEPY, p53) Analisi molecolare se appropriato

Esclusione di infezioni virali (HCV, HIV, CMV, EBV, altre) Indagini raccomandate nel follow-up

Emocromo con formula e biochimica clinica ad intervalli di 1–6 mesi In caso di evidente sospetto di MDS: esame midollare

Steensma et al, Blood 2015;126:9

CHIP: Clonal hematopoiesis of undetermined potetial ICUS: idiopatic cytopenia of undetermined significance CCUS: clonal cytopenia of undetermined signficance

Citogenetica

• La citogenetica ha un ruolo decisivo

nella diagnosi e nella definizione

della prognosi

• Anomalie citogenetiche sono

riscontrabili del 40-70% delle MDS

de novo e nel 95% delle forme

secondarie a chemioterapia

(therapy-related)

Anomalie cromosomiche e MDS

Recurrent cytogenetic abnormalities in MDS

Citogenetica e sopravvivenza

Karyotype

•Good: normal, -Y, del(5q), del(20q) •Intermediate: other abnormalities

2016 WHO classification of myeloid neoplasms and

acute leukemia

Evolution of MDS classification systems

RA

RARS

RAEB-1

RAEB 2

Sindrome da

5q-• Presentazione clinica

– Età avanzata

– Sesso femminile (F:M 7:3)

– Basso rischio di progressione in LAM – Buona prognosi

• Quadro ematologico

– Anemia macrocitica – Modesta leucopenia

– Normale/elevato numero di piastrine – ipoplasia eritroide midollare

– Megacariociti monolobati

– Delezione intestiziale braccio lungo del cromosoma 5 come singola anomalia – Blasti < 5%

MDS: clinical findings

• Clinical features are non-specific and mainly result from cytopenias.

• Anaemia, is symptomatic in many pts, leading to fatigue, poor quality of life, and destabilisation of underlying cardiovascular disease.

• Thrombocytopenia is commonly associated with platelet dysfunction, potentially leading to bleeding symptoms even in moderate thrombocytopenia.

• Infections (especially with gram-neg bacilli, gram-pos cocci, and fungi) can occur with only moderate neutropenia due to neutrophil function defects.

• Many patients have immune disorders, including relapsing polychondritis, vasculitis, and seronegative polyarthritis.

– The two disorders tend to be diagnosed almost simultaneously, which suggests a pathophysiological relation.

MDS: Differential diagnosis

• All other causes of cytopenias must be carefully excluded; – vitamin deficiencies – autoimmune disease, – Liver disease, – hypersplenism, – viral infections, – drug intake,

– exposure to environmental toxins, – aplastic anaemia,

– Acute leukemias

– Large granular lymphocytic leukemia – Hairy cell leukemia

– Myelofibrosis

– Paroxysmal nocturnal haemoglobinuria, – bone-marrow infiltration by malignancy,

therapy related MDS

• Rischio attuariale 0.25-1% per anno da 2 a 5-7 anni dalla fine della chemioterapia

• Rischio dose dipendente e aumenta esponenzialmente dopo i 40 anni

Survival MDS by subtype in the USA

(Surveillance, Epidemiology, and End Results data, based on the November 2017 submission).

Prognostic factors in MDS

International prognostic Scoring System

Risk stratification, scores, and median OS by each model.

Aziz Nazha, ASH 2018

• Current models can overestimate or underestimate the OS for some MDS pts. •

• Recognizing this limitation of current models is very important as the choice of therapy

and disease expectations are highly dependent on prognosis, and identifying the actual risk in these patients could alter their treatment recommendations

Comorbidities in MDS

MDS comorbidity score

terapia

• Trapianto di cellule staminali (nei pazienti fit e “giovani”)

– Allogenico

• Terapia di supporto

– Trasfusioni,

– Fattori di crescita: Epo, G-CSF

– antibiotici,

– etc

• Chemioterapia

• Terapia immunosoppressiva: ciclosporina, globulina antilinfocitaria (cariotipo

normale / trisoma 8)

• Farmaci immunomodulanti: lenalidomide (del5q)

• Agenti ipometilanti: 5 azacitidina, decitabina

Platzbecker U. Blood. 2019;133(10):1096-1107)

Priorities of

interventions in MDS

according to stage

Platzbecker U. Blood. 2019;133(10):1096-1107)

Historical time scale of registration of therapeutic

agents forMDS in the EU and United States.

P la tzb e c k e r U. Blood. 2 0 1 9 ;1 3 3 (1 0 ): 1 0 9 6 -1 1 0 7 )

Therapeutic

algorithm in

LR-MDS.

ATG, antithymocyte globulin; CSA, cyclosporine;

HMA, hypomethylating agent; LEN, lenalidomide;

LUSP, luspatercept; sEPO, serum EPO;

TPO-RA, thrombopoietin receptor agonist.

*Not presently approved.

P la tzb e c k e r U. Blood. 2 0 1 9 ;1 3 3 (1 0 ): 1 0 9 6 -1 1 0 7 )

Therapeutic

algorithm in

HR-MDS.

IC, induction chemotherapy; BSC, best supportive care; TKI; tyrosine kinase inhibitor. *These could be IDH or

FLT3-inhibitors (not presently approved). †Consider posttransplant disease surveillance strategies

Platzbecker U. Blood. 2019;133(10):1096-1107)

Diagram depicting myeloid

disorders with clinical and

genetic features shared

with MDS and the degree

to which they are driven by

proliferative and

immunologic mechanisms.

Diagnostic criteria for MDS/MPN with ring sideroblasts and thrombocytosis

• Anemia associated with erythroid lineage dysplasia with or without

multilineage dysplasia≥15% ring sideroblasts*, <1% blasts in PB and <5% blasts in the BM

• Persistent thrombocytosis with platelets ≥450 x 109_/L

• Presence of a SF3B1 mutation or, in the absence of SF3B1 mutation,

no history of recent cytotoxic or growth factor therapy that could explain the myelodysplastic/myeloproliferative features†

• No BCR-ABL1 fusion gene, no rearrangement of PDGFRA, PDGFRB, or

FGFR1; or PCM1-JAK2; no (3;3)(q21;q26), inv(3)(q21q26) or del(5q)‡

• No preceding history of MPN, MDS (except MDS-RS), or other type of

MDS/MPN Schmi tt -G ra ef f A H, Ha e m at ol ogic a. 20 08 ; 93 :34

*At least 15% ring sideroblasts required even if SF3B1 mutation is detected. †A diagnosis of MDS/MPN-RS-T is strongly supported by the presence of SF3B1 mutation together with a mutation in JAK2 V617F, CALR, or MPL genes.

‡In a case which otherwise fulfills the diagnostic criteria for MDS with isolated del (5q)-no or minimal absolute basophilia; basophils usually ,2% of leukocytes.

CMML

T an aka T N , B lo o d . 2019; 133(10) :108 6 -109 5